ASTHMA

I. DEFINITION
According to world health organization, Asthma is the
most common chronic disease in children in developed
countries, affecting approximately 12 percent of children
who are less than 18 years of age. It is more common in
males than females under the age of 15 years.
Asthma is a chronic condition with symptoms of cough,
wheezing, chest tightness or pain, and/or difficulty
breathing. These symptoms occur periodically, usually
related to specific triggering events. People with asthma
Figure 1.1
have narrowed, small airways during these episodes; the
narrowing is partially or completely reversible with asthma treatments. In addition, the airways
of children with asthma react to a variety of stimuli, which may include viral illnesses (e.g., the
common cold), exercise, pollen, foods to which the child is allergic, or environmental conditions.

How asthma is classified

To classify your asthma severity, your doctor considers your answers to questions about
symptoms (such as how often you have asthma attacks and how bad they are), along with the
results of your physical exam and diagnostic tests. Determining your asthma severity helps your
doctor choose the best treatment. Asthma severity often changes over time, requiring treatment
adjustments.
Asthma is classified into four general categories:
Asthma Signs and Symptoms
Classification
Mild intermittent Mild symptoms up to two days a week and up to two nights a month

Mild persistent Symptoms more than twice a week, but no more than once in a single day

Moderate persistent Symptoms once a day and more than one night a week

Severe persistent Symptoms throughout the day on most days and frequently at night

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II. RISK FACTORS

Asthma occurs when the small airways (bronchi) in the lungs become inflamed and
narrowed, which limits the flow of air out of the lungs. This narrowing is almost always
reversible in children with treatment. Many different genetic, infectious, and environmental
factors may increase the risk of developing asthma, a few of which include:

a. Viral infections People who have wheezing with respiratory syncytial virus or
rhinovirus seem to be at increased risk for developing asthma.
b. Pollution Increased exposure to indoor and outdoor pollution may increase the risk
of developing asthma.
c. Exposure to tobacco smoke Exposure to tobacco smoke during pregnancy and
throughout childhood increases the risk of developing asthma.
d. Family history Anyone with a personal or family history of certain medical
problems, such as asthma, allergies, or eczema, are at increased risk of developing
asthma.
e. Stress Severely negative life events in children increase the risk of asthma attacks
over the subsequent few weeks.
However, not all with asthma have known risk factors. In other words, even who live in
unpolluted areas and whose parents do not smoke or have asthma can develop asthma.
i. Predisposing/Precipitating Factors
o Non-modifiable Factors:
Gender
Childhood asthma occurs more frequently in boys than in girls. It's
unknown why this occurs although some experts find a young male's airway
size is smaller when compared to the female's airway, which may contribute
to increased risk of wheezing after a cold or other viral infection.
Around age 20, the ratio of asthma between men and women is the same.
At age 40, more females than males have adult asthma.
Family history of asthma
An inherited genetic makeup predisposes one to having asthma. In
fact, it's thought that three-fifths of all asthma cases are hereditary.

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According to a CDC report, if a person has a parent with asthma, he or she

is three to six times more likely to develop asthma than someone who does
not have a parent with asthma.
o Modifiable Factors:
Exposure to environmental allergens
Exposure to house dust, mites, animal allergens, and fungi can irritate the
mucosal lining of the nasal cavity and lead to airway hyperactivity.
Emotional factors or stress
GERD
The existence of acid in the distal esophagus, mediated via vagal or
other neural reflexes, can significantly increase airway resistance and
airway reactivity. Patients with asthma are 3 times more likely to also have
GERD.

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III. PATHOPHYSIOLOGY
a. Schematic Diagram(Lifted from the book Pathophysiology 2nd Edition by Paradiso)

Modifiable Factors:
Non-modifiable Factors: >Environmental Allergens
>Gender >Emotional factors/Stress
>Family History >GERD

Triggers airway inflammation

Release of mast cells, eosinophils, histamine,

macrophages, and activated T lymphocytes

Acute bronchoconstriction Goblet cells increase

mucus production

Narrowing of the Wheezing

airway passages
Cough

Difficulty of breathing

Oxygenation

Chest tightness

b. Synthesis of the Disease

Bronchial asthma is a prolonged lung disorder resulting from the spasmodic
contraction of the bronchial muscles. It is most often referred to simply as asthma.
Triggered by hyperactivity in the lungs, bronchial asthma is characterized by
recurring attacks of clogged airways, causing shortness of breath, coughing, wheezing and

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feelings of tightness in the chest. According to the GINA, more than 28 million Americans,
including 7.8 million children under age 18, suffer with asthma today.
Allergies are strongly linked to asthma and to other respiratory diseases such as
chronic sinusitis, middle ear infections, and nasal polyps. Most interestingly, a recent
analysis of people with asthma showed that those who had both allergies and asthma were
much more likely to have nighttime awakening due to asthma, miss work because of
asthma, and require more powerful medications to control their symptoms.
Asthma is associated with mast cells, eosinophils, and T lymphocytes. Mast cells
are the allergy-causing cells that release chemicals like histamine. Histamine is the
substance that causes nasal stuffiness and dripping in a cold or hay fever, constriction of
airways in asthma, and itchy areas in a skin allergy. Eosinophils are a type of white blood
cell associated with allergic disease.
T lymphocytes are also white blood cells associated with allergy and inflammation.
The presence of airway hyper responsiveness or bronchial hyper reactivity in asthma is an
exaggerated response to numerous exogenous and endogenous stimuli. The mechanisms
involved include direct stimulation of airway smooth muscle and indirect stimulation by
pharmacologically active substances from mediator-secreting cells such as mast cells or
non-myelinated sensory neurons.
The degree of airway hyper responsiveness generally correlates with the clinical
severity of asthma.
IV. CLINICAL MANIFESTATION
a. Signs and Symptoms with Rationale
Shortness of breath
SOB occurs when airway gets obstructed by various reasons such as
bronchoconstriction, bronchospasm, and edema of the airway, which can happen in
response to any stimuli that triggered airway hyperactivity. Bronchoconstriction is
caused by the release of histamine.
Wheezing
Wheezing, especially upon expiration can be heard because air coming out from
the bronchioles is passing through narrowed air passages, leading to a whistling sound.

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Cough
Irritation of the airway passages, such as the bronchioles, can trigger mucus
production as a response. The presence of mucus in the airway passages can stimulate
the cough reflex in order to expel these mucus secretions out of the passages. Cough
can also be a mechanism to draw more air into inflamed passages.
Chest tightness
Chest tightness is possible due to a decrease in oxygenation while having asthma
attacks. Due to narrowed bronchi, air, including oxygen, is depleted, leading to a
feeling of chest tightness.
Excess mucus production
This is a response to the stimuli that triggered airway hyperactivity and
inflammation.
b. Coughing and wheezing

Symptoms of asthma in children include coughing and wheezing. The cough is usually
dry and hacking and is most noticeable while the child sleeps and during early morning hours.
It may also be triggered by exercise or cold air exposure. Wheezing is a high-pitched, musical
noise that is usually heard when the child breathes out. It can generally only be heard with a
stethoscope.

Coughing and wheezing tends to come and go during the day or night, depending upon
the degree of airway narrowing in the lungs. Breathlessness, chest tightness or pressure, and
chest pain may also occur. In addition to coughing or wheezing, a child may report that his or
her chest or stomach hurts.

c. Asthma triggers

Wheezing and coughing may occur at any time, but certain triggers are known to
worsen asthma in many children.

d. Environmental conditions

Cold air, changes in barometric pressure, rain, or wind may cause increased asthma
symptoms in certain people. Pollution, including exhaust fumes and particulate matter, may
also induce symptoms.

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e. Upper respiratory infections

Viral upper respiratory infections (head and chest colds) are a common trigger of
asthma in infants and young children. The most common viral infections include rhinovirus
(the virus that causes most colds), respiratory syncytial virus, and influenza virus.)

Children with asthma should use their asthma treatments for cough and chest
congestion rather than over-the-counter cold remedies.

f. Exercise

Narrowing of the airways can be triggered by exercise. This is called exercise-induced

asthma (also called exercise-induced bronchoconstriction or EIB).

Breathlessness, wheeze, and/or cough usually occur within 5 to 10 minutes of the

cool-down period after vigorous exercise, but may occur during exercise. These symptoms
tend to disappear after 20 to 45 minutes. Certain types of exercise (e.g., swimming) are less
likely to cause exercise-induced asthma than others (e.g., running, skating), probably because
they produce less airway cooling and drying. Short bursts of activity tend to be better tolerated
than prolonged exercise.

g. Allergens and irritants

Indoor and outdoor allergens are an important trigger of childhood asthma, particularly
for children older than three years of age. In children with seasonal allergies, asthma symptoms
may worsen during certain pollen seasons. Symptoms can also flare as a result of mold
exposure (e.g. during rainy seasons or in damp areas). Indoor pollutants can act as irritants and
also trigger asthma symptoms. Irritants and allergens include:
House dust (i.e. dust mites, cockroaches, mice droppings), particularly during vacuuming
Animal exposures; cats and dogs are especially provocative, but other furry animals (gerbils,
rabbits, hamsters, etc.) may be suspect, particularly if symptoms only occur in settings where
these animals reside
Pollens (the pollen season and types of pollen vary depending upon the region and climate)
Molds

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Indoor pollutants (e.g. paint, perfume, cleaning products, space heaters, gas stoves, room
deodorizers)

If allergies are a possible cause of symptoms, skin or blood testing may be

recommended. This can help to both identify triggers and determine the necessity of avoiding
these triggers at home.

Symptom patterns

Having with chronic asthma may have one of several distinct patterns of symptoms, and
the asthma pattern may change over time:
Intermittent asthma attacks with no symptoms between attacks.
Chronic symptoms with intermittent worsening
Attacks that become more severe or frequent over time
Morning "dipping," when symptoms worsen in the morning and improve as the day
progresses
Symptoms that begin during upper respiratory tract infections (e.g. colds) and linger for
several weeks after, with resolution during warmer weather.

Most asthma attacks develop slowly over a period of several days. Uncommonly, a severe
attack can occur suddenly, even in someone with intermittent asthma, and with minimal
warning.
V. DIAGNOSTIC PROCEDURES
The diagnosis of asthma in requires a careful review of a current and past medical history,
family history, and a physical examination. Specialized testing is sometimes needed to
diagnose asthma and to rule out other possible causes of symptoms. Many people with asthma
appear and sound completely normal.
Tests to measure lung function
You may also be given lung (pulmonary) function tests to determine how much air moves
in and out as you breathe. These tests may include:

a. Spirometry testing

Spirometry measures the flow and volume of air blown out after a child takes a very deep
breath and then forcefully exhales.
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If airflow obstruction is present, the test may be repeated after the child uses an asthma
inhaler or nebulizer (bronchodilator) to confirm that the obstruction is reversible (a feature of
asthma). Children younger than six years sometimes have a hard time following the
instructions to perform spirometry. Testing of younger children and infants is described below.

b. Challenge testing

A bronchial challenge test may be recommended to diagnose asthma. This testing is

designed to cause the airways to narrow in children with asthma. The most common challenge
tests include inhaling an agent (e.g. methacholine) that causes bronchoconstriction, exercise
by running on a treadmill or using an exercise cycle, or breathing cold air. Testing is done in a
specialized asthma testing center that is capable of providing emergency asthma care if needed.
b. Peak flow
A peak flow meter is a simple device that measures how hard you can breathe out. Lower
than usual peak flow readings are a sign your lungs may not be working as well and that your
asthma may be getting worse. Your doctor will give you instructions on how to track and deal
with low peak flow readings.
Lung function tests often are done before and after taking a medication called a
bronchodilator, such as albuterol, to open your airways. If your lung function improves with
use of a bronchodilator, it's likely you have asthma.
Additional tests
Other tests may be recommended to ensure that another condition is not the cause
of a child's coughing or wheezing. This may include a chest X-ray, sweat chloride test (for
cystic fibrosis), barium swallow (for gastroesophageal reflux), modified barium swallow
(for aspiration), or skin or blood testing (for allergies or immune problems).

Other tests to diagnose asthma include:

Methacholine challenge
Methacholine is a known asthma trigger that, when inhaled, will cause mild constriction of
your airways. If you react to the methacholine, you likely have asthma. This test may be used
even if your initial lung function test is normal.

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Nitric oxide test.

This test, though not widely available, measures the amount of the gas, nitric oxide that
you have in your breath.
When your airways are inflamed sign of asthma you may have higher than normal nitric
oxide levels.
Imaging tests
A chest X-ray and high-resolution computerized tomography (CT) scan of your lungs and
nose cavities (sinuses) can identify any structural abnormalities or diseases (such as infection)
that can cause or aggravate breathing problems.
Allergy testing
This can be performed by a skin test or blood test. Allergy tests can identify allergy to pets,
dust, mold and pollen. If important allergy triggers are identified, this can lead to a
recommendation for allergen immunotherapy.
Sputum eosinophils
This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus
(sputum) you discharge during coughing. Eosinophils are present when symptoms develop and
become visible when stained with a rose-colored dye (eosin).
Provocative testing for exercise and cold-induced asthma
In these tests, your doctor measures your airway obstruction before and after you perform
vigorous physical activity or take several breaths of cold air.
VI. MEDICAL MANAGEMENT
i. Pharmacologic Therapy
a. Short-acting beta2
Adrenergic agonists, these are the medications of choice for relief of acute
symptoms and prevention of exercise-induced asthma.
b. Anticholinergics
Anticholinergics, inhibit muscarinic cholinergic receptors and reduce
intrinsic vagal tone of the airway.
c. Corticosteroids.
Corticosteroids are most effective in alleviating symptoms, improving airway
function, and decreasing peak flow variability.

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d. Leukotriene modifiers
Anti-Leukotrienes are potent Broncho constrictors that also dilate blood
vessels and alter permeability.
e. Immunomodulatory
Prevent binding of IgE to the high affinity receptors of basophils and mast
cells.
ii. Peak Flow Monitoring
a. Peak flow meters
Peak flow meters measure the highest airflow during a forced expiration.
b. Daily peak flow monitoring
This is recommended for patients who meet one or more of the following
criteria: have moderate or severe persistent asthma, have poor perception of
changes in airflow or worsening symptoms, have unexplained response to
environmental or occupational exposures, or at the discretion of the clinician or
patient.
c. Function
If peak flow monitoring is used, it helps measure asthma severity and, when
added to symptom monitoring, indicates the current degree of asthma control.
VII. NURSING ASSESSMENT & PROBLEMS
i. Assessment of a patient with asthma includes the following:
Assess for breath sounds.
Assess the patients peak flow.
Monitor the patients vital signs.
Assess the level of oxygen saturation through the pulse oximeter.
Assess the patients respiratory status by monitoring the severity of the symptoms.
ii. Nursing Diagnosis
Based on the data gathered, the nursing diagnoses appropriate for the patient with
asthma include:
a. Ineffective airway clearance related to increased production of mucus and
bronchospasm.
b. Impaired gas exchange related to altered delivery of inspired O2.

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c. Anxiety related to perceived threat of death.

iii. Nursing Care Planning & Goals
5 Bronchial Asthma Nursing Care Plans
To achieve success in the treatment of a patient with asthma, the following goals
should be applied:
Expectoration of secretions.
Maintenance of airway patency.
Demonstration of behaviors to improve or maintain clear airway.
Verbalization of understanding of causes and therapeutic management regimen.
Identification of potential complications and how to initiate appropriate
preventive or corrective actions.
Demonstration of absence/reduction of congestion with breath sounds clear,
respirations noiseless, improved oxygen exchange.
iv. Nursing Interventions
The nurse generally performs the following interventions:

a. Assess history
Obtain a history of allergic reactions to medications before administering
medications.
b. Assess respiratory status
Assess the patients respiratory status by monitoring the severity of
symptoms, breath sounds, peak ow, pulse oximetry, and vital signs.
c. Assess medications
Identify medications that the patient is currently taking. Administer
medications as prescribed and monitor the patients responses to those
medications; medications may include an antibiotic if the patient has an
underlying respiratory infection.
d. Pharmacologic therapy
Administer medications as prescribed and
monitor patients responses to medications.
e. Fluid therapy
Administer fluids if the patient is dehydrated.

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f. Evaluation
To determine the effectiveness of the plan of care, evaluation must be
performed.
The following must be evaluated:
Maintenance of airway patency.
Expectoration or clearance of secretions.
Absence /reduction of congestion with breath sound clear, noiseless respirations,
and improved oxygen exchange.
Verbalized understanding of causes and therapeutic management regimen.
Demonstrated behaviors to improve or maintain clear airway.
Identified potential complications and how to initiate appropriate preventive or
corrective actions.
g. Discharge and Home Care Guidelines
A major challenge is to implement basic asthma management principles at the
home and community level.
v. Collaboration
The complex therapy of treating asthma at home needs collaboration between the
patient and the health care provider to determine the desired outcomes and to formulate
a plan to achieve those outcomes.
vi. Health education
Patient teaching is a critical component of care for patients with asthma. Teach
patient and family about asthma (chronic inammatory), purpose and action of
medications, triggers to avoid and how to do so, and proper inhalation
technique. Instruct patient and family about peak-ow monitoring. Obtain current
educational materials for the patient based on the patients diagnosis, causative factors,
educational level, and cultural background.
vii. Compliance to therapy
Nurses should emphasize adherence to the prescribed therapy, preventive
measures, and the need to keep follow-up appointments with health care
providers. Teach patient how to implement an action plan and how and when to seek
assistance.

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viii. Home visits

Home visits by the nurse to assess the home environment for allergens may
be indicated for patients with recurrent exacerbations.
VIII. NURSING MANAGEMENT
The immediate care of patients with asthma depend on the severity of the symptoms. The
patient and family are often frightened and anxious because of the patients
dyspnea. Therefore, a calm approach is an important aspect of care.
Administer uids if the patient is dehydrated.
Assist with intubation procedure, if required.
Identify medications the patient is currently taking.
Obtain a history of allergic reactions to medications before administering
medications.
Assess the patients respiratory status by monitoring the severity of symptoms,
breath sounds, peak ow, pulse oximetry, and vital signs.
Administer medications as prescribed and monitor the patients responses to those
medications; medications may include an antibiotic if the patient has an underlying
respiratory infection.
a. Teaching Points
Instruct patient and family about peak-ow monitoring.
Teach patient how to implement an action plan and how and when to seek
assistance.
Obtain current educational materials for the patient based on the patients
diagnosis, causative factors, educational level, and cultural background.
Teach patient and family about asthma (chronic inammatory), purpose and
action of medications, triggers to avoid and how to do so, and proper inhalation
technique.
b. Continuing Care
Refer for home health nurse as indicated.
Refer patient to community support groups.
Home visit to assess for allergens may be indicated (with recurrent exacerbations).

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Emphasize adherence to prescribed therapy, preventive measures, and need for

follow up appointments.
Remind patients and families about the importance of health promotion strategies
and suggested health screening.
c. Documentation Guidelines
Response to medications, oxygen therapy, hydration, bedrest.
Presence of complications: Respiratory failure, ruptured bleb that may result in a
pneumothorax.
Respiratory status: Patency of airway, auscultation of the lungs, presence or
absence of adventitious breath sounds, respiratory rate and depth.

IX. JOURNAL ARTICLE: Current Trends

A. CONCLUSION
Asthma is an increasing problem in this country and around the
world. Although medications for the treatment of asthma abound and are improving,
there are inherent risks and side effects with all of them. Intravenous magnesium has
been employed in the treatment of acute asthma, but its use has not become universal,
nor has it been studied for the treatment of chronic asthma. It is known to be a safe
drug with minimal side effects. In this study, the author investigates the use of
magnesium and other nutrients in the treatment of both acute and chronic asthma.

The use of intravenous treatment with multiple nutrients, including

magnesium, for acute and chronic asthma may be of considerable benefit.
Pulmonary function improved progressively the longer patients received treatment.

The introduction of leukotriene antagonists and synthesis inhibitors in the

therapy of asthma will represent an important breakthrough in asthma therapy. These
drugs represent the first class of mediator antagonists that have provided clinical
benefit in asthma, in contrast to the disappointing results seen with very potent
histamine antagonists. Although further work needs to be done, one should be

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optimistic as to their future contribution in the management of asthma; they are

likely to become an established class of anti-asthma drugs.

Appropriate medication and education are 2 important factors that influence

the successful prevention of asthma exacerbation. ICS reduces asthma symptoms,
increases lung function, improves quality of life, and reduces the risks of
exacerbation, asthma-related hospitalizations, and death. The present study revealed
gradually increasing rates of using medications at home (e.g., ICS, ICS/LABA, and
LTRA), as recommended by the Global Initiative for Asthma guidelines and other
relevant bronchial asthma guidelines. However, these increases remain insufficient
(ICS: 20.38%, ICS/LABA: 10.66%, and LTRA: 9.4%), and the usage rates are much
lower than those in developed countries. These changes are likely influenced by
improved treatment adherence among patients with asthma, which is related to
reformed education approaches, good doctor/patient partnerships, and an increased
level of medical service in the Chinese population. However, the medical insurance
system may not evenly cover all patients, and socioeconomic status varies greatly
between different Chinese cities. Moreover, many patients express worry regarding
adverse drug reactions, and ineffective treatment remains a vital cause of asthma
exacerbation. Thus, the prevention of asthma attacks may be improved through more
appropriate asthma therapy, further improving patient compliance, and providing
more culturally and linguistically appropriate asthma education.

B. RECOMMENDATION
Lifestyle changes and ongoing care can help manage the condition. The most important step is to
not start smoking and avoiding other lung irritants such as second hand smoke, dust, fumes, vapors
and air pollution to help lungs healthy. Another thing is to follow a healthy diet and be physically
active as you can. A healthy diet includes a variety of fruits, vegetables, and whole grains. It also
includes lean meats, poultry, fish, and fat-free or low-fat milk or milk products. A healthy diet also
is low in saturated fat, trans-fat, cholesterol, sodium (salt), and added sugar.
X. REFERENCE/S
Book/s
Pathophysiology 2nd Edition by Catherine Paradiso: Asthma (page 11)

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Pathophysiology for the Health Professions 3rd Edition by Barbara E. Gould

Journal/s
Prevalence trends in the characteristics of patients with allergic asthma in
Beijing, 1994 to 2014
Mao, Dan PhD; Tang, Rui MD; Wu, Rui MD; Hu, Hong PhD*; Sun, Lu Jin MD;
Zhu, Hong MB; Bai, Xue MS; Han, Jing Guo MS

Section Editor(s): Liu., Jian

Medicine: June 2017 - Volume 96 - Issue 22 - p e7077

doi: 10.1097/MD.0000000000007077

Research Article: Observational Study

http://journals.lww.com/md-
journal/Fulltext/2017/06020/Prevalence_trends_in_the_characteristics_of.52.aspx
https://waojournal.biomedcentral.com/articles/10.1186/1939-4551-7-1
http://www.usdoctor.com/NewPage/asthma.html
Webliography
https://medlineplus.gov/asthma.html
http://www.aafa.org/page/asthma-facts.aspx
https://www.epa.gov/asthma/2016-asthma-fact-sheet
http://www.aaaai.org/conditions-and-treatments/asthma
http://www.aaaai.org/about-aaaai/newsroom/asthma-statistics
http://www.worldlifeexpectancy.com/country-health-profile/philippines
http://www.mayoclinic.org/diseases-conditions/asthma/basics/tests-diagnosis/con-
20026992
https://www.uptodate.com/contents/asthma-symptoms-and-diagnosis-in-children-
beyond-the-basics

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